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Everyone is familiar with PONV preventive drugs, but their clinical applications are varied
Everyone is familiar with PONV preventive drugs, but their clinical applications are varied
How to administer and when to administer to achieve the best results? How to administer and when to administer to achieve the best results?
Dosage and timing of traditional preventive antiemetic drugs:
Dosage and timing of traditional preventive antiemetic drugs:1.
1.
2.
.
4.
5 , corticosteroid, dexamethasone single be usual adult dose .
5-HT3 receptor antagonists, glucocorticoids, and droperidol are the most effective drugs for preventing PONV with the least side effects.
When different types of anti- PONV drugs are used in combination, the effects are added but the side effects are usually not superimposed, so the combination of drugs is better than the single drug
How should PONV patients be treated for non-preventive medications or preventive medications that are ineffective ? How should PONV patients be treated for non-preventive medications or preventive medications that are ineffective ?
1.
1.
2.
3.
4.
5.
6.
If PONV occurs 6 hours after surgery , it may be considered to give 5-HT 3 receptor antagonist and droperidol repeatedly , with the same measurement as mentioned above .
7.
When the patient develops PONV in the recovery room after anesthesia, the application of propofol treatment can be considered, 20mg or increase or decrease according to the need
.
However, it should be noted that the antiemetic effect of small doses of propofol may be short-lived
.
When the patient develops PONV in the recovery room after anesthesia, the application of propofol treatment can be considered, 20mg or increase or decrease according to the need
.
However, it should be noted that the antiemetic effect of small doses of propofol may be short-lived
.
The new type of stop spouting drug was
The new type of stop spouting the drug was a new type stop spouting drug was•The second generation 5-HT3 receptor antagonist : Palonosetron
•The second generation 5-HT3 receptor antagonist : PalonosetronThe second-generation 5-HT3 receptor antagonists are gradually gaining popularity , such as ramosetron and palonosetron
.
Palonosetron for 5-HT3 receptor binding force and higher specificity selective affinity , for the NK- 1 receptors are also inhibited , it has a longer half-life
.
The recommended dose in the guidelines is 0.
075 mg intravenously
.
.
Palonosetron for 5-HT3 receptor binding force and higher specificity selective affinity , for the NK- 1 receptors are also inhibited , it has a longer half-life
.
The recommended dose in the guidelines is 0.
075 mg intravenously
.
A meta-analysis showed that Palonosetron (0.
075 mg) is more effective than traditional antiemetic drugs ( level of evidence : A1)
.
075 mg) is more effective than traditional antiemetic drugs ( level of evidence : A1)
.
Safety , palonosetron The most common adverse events were constipation, transient elevated liver enzymes, headache , but Palonosetron is the only one that does not affect the QTc interval ( reflecting the cardiac depolarization and the role of very complex index ) of the 5-HT3 receptor antagonists
.
Palonosetron may be an effective antiemetic drug with minimal side effects in children , but the lowest effective dose is not yet clear
.
.
Palonosetron in children in treatment may be a side effect and minimum effective antiemetic for children , but the lowest effective dose is not yet clear
.
• NK-1 receptor antagonist : aprepitant
• NK-1 receptor antagonist : aprepitantMainly through the brain NK- 1 binding receptor selectivity , inhibition of P substance play antiemetic effect , on behalf of drug: aprepitant
.
It has a weak affinity for both 5-HT3 receptors and dopamine receptors , and its half-life is 40 h
.
.
It has a weak affinity for both 5-HT3 receptors and dopamine receptors , and its half-life is 40 h
.
The guideline recommendation is to take 40 mg aprepitant
orally before induction of anesthesia .
Studies have shown , aprepitant 40 mg orally with palonosetron 0.
075 mg intravenous antiemetic effect quite , but better than ondansetron
.
orally before induction of anesthesia .
Studies have shown , aprepitant 40 mg orally with palonosetron 0.
075 mg intravenous antiemetic effect quite , but better than ondansetron
.
• Glucocorticoid : Methylprednisolone
Methylprednisolone prevention of PONV mechanism remains unclear , probably in solitary tract nucleus of the central nervous system and anti-inflammatory effects and directly related to the role , medication is no different adverse reactions with dexamethasone
.
The 2019 version of the guidelines suggests that methylprednisolone 40 mg intravenously is effective in preventing delayed-onset PONV .
.
The 2019 version of the guidelines suggests that methylprednisolone 40 mg intravenously is effective in preventing delayed-onset PONV .
The recommended dose of methylprednisolone in this version of the guidelines is still 40 mg intravenously , and the optimal timing of administration has not yet been recommended .
The meta-analysis adopted by the guidelines shows that methylprednisolone ( 40-125 mg) can reduce hip and knee surgery.
The incidence of posterior pain and PONV .
The meta-analysis adopted by the guidelines shows that methylprednisolone ( 40-125 mg) can reduce hip and knee surgery.
The incidence of posterior pain and PONV .
• Dopamine receptor antagonist : amisulpride
• Dopamine receptor antagonist : amisulpride
• Dopamine receptor antagonist : amisulpride
Amisulpride is an intravenous preparation approved by the FDA for PONV management recently .
It is a dopamine D2 and D3 receptor antagonist and an oral antipsychotic
.
.
The guidelines recommend that administering 5 mg amisulpride intravenous preparation during induction of anesthesia can reduce the incidence of postoperative nausea .
If the patient has previously received a non-dopamine receptor antagonist to prevent PONV, it is recommended that 10 mg amisulpride must be used for PONV .
Salvage treatment
.
If the patient has previously received a non-dopamine receptor antagonist to prevent PONV, it is recommended that 10 mg amisulpride must be used for PONV .
Salvage treatment
.
• Other drugs : gabapentin
• Other drugs : gabapentinPreoperative 1 ~ 2 h oral gabapentin 600 ~ 800 mg can reduce PONV risk , level of evidence for the A1 level
.
However, according to 2019 US Food and Drug Administration issued a drug safety communication warning , when a portion of gabapentin as multimodal analgesia scheme to use , reduce intraoperative use of opioids while patients should be alert to the risk of respiratory depression , especially Elderly patients
.
.
However, according to 2019 US Food and Drug Administration issued a drug safety communication warning , when a portion of gabapentin as multimodal analgesia scheme to use , reduce intraoperative use of opioids while patients should be alert to the risk of respiratory depression , especially Elderly patients
.
Multi- mode type pre- preventing side case
Multi- mode type pre- preventing side case multi- mode type pre- preventing side caseMore and more studies support multi-mode programs to prevent PONV, including not only the combination of different classes of antiemetics , also includes a combination drug and non-drug techniques , for example , antiemetic drugs and acupuncture Technology Associates , antiemetic drugs and more than Model analgesia technology joint and so on
.
.
In a variety of drug combination prevention programs, the list of several combinations is for reference only
.
.
▪ 5-HT receptor antagonist + dexamethasone (4 mg or 8 mg)
▪ Aprepitant 80 mg + dexamethasone 4 ~ 8mg + Ondansetron 4mg
▪ Aprepitant 80 mg + dexamethasone 4 ~ 8mg + Ondansetron 4mg▪ For children with intermediate-risk PONV , use 5-HT receptor antagonists and glucocorticoids in combination .
Among them, ondansetron (50-100 μg/kg) + dexamethasone (150 μg/kg) is the most common combination
.
For high-risk children, it is recommended to add total intravenous anesthesia ( TIVA ) on this basis .
.
For high-risk children, it is recommended to add total intravenous anesthesia ( TIVA ) on this basis .
Comprehensive management of postoperative nausea and vomiting
Comprehensive management of postoperative nausea and vomiting2016 Nian , the United States accelerated rehabilitation Association (ASER) released a statement Experts: All patients should receive perioperative PONV prevention, for the treatment and prophylaxis of the amount of change and should be determined by the number of risk factors can not be changed, the use of the drug should have different mechanisms of action , in order to realize the benefits of multimodal prevention
.
.
This guide gives recommendations for various intraoperative ERAS programs for the management of PONV .
The recommended interventions generally include TIVA , minimum preoperative fasting time, adequate hydration and multimodal analgesia to reduce opioids Application .
The recommended interventions generally include TIVA , minimum preoperative fasting time, adequate hydration and multimodal analgesia to reduce opioids Application .
Fasting on water and adequate hydration before surgery , before the recommended anesthesia 2 h to give patients clear non-alcoholic beverages , before anesthesia 6 h to give light meal , patients require bowel preparation , may be appropriate to give intravenous fluids , surgery Pay attention to liquid management and so on
.
.
Although its purpose is to correct and maintain the patient's water and electrolyte balance , it is also of great significance for the prevention of PONV .
references:
references:[1] Gan TJ, Belani KG, Bergese S, et al.
Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting [J].
Anesth Analg, 2020, 131: 411- 448.
Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting [J].
Anesth Analg, 2020, 131: 411- 448.
[2] Ormel G, Romundstad L, Lambert-Jensen P, et al.
Dexam- ethasone has additive effect when combined with ondansetron and droperidol for treatment of established PONV [J].
Acta Anaesthesiol Scand, 2011, 55: 1196- 1205.
Dexam- ethasone has additive effect when combined with ondansetron and droperidol for treatment of established PONV [J].
Acta Anaesthesiol Scand, 2011, 55: 1196- 1205.
[3] Gupta R, Soto R.
Prophylaxis and management of postopera-tive nausea and vomiting in enhanced recovery protocols: Expert Opinion statement from the American Society for En-hanced Recovery (ASER) [J].
Perioper Med (Lond), 2016 , 5: 4.
Prophylaxis and management of postopera-tive nausea and vomiting in enhanced recovery protocols: Expert Opinion statement from the American Society for En-hanced Recovery (ASER) [J].
Perioper Med (Lond), 2016 , 5: 4.
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